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REPUBLIC OF THE PHILIPPINES)

QUEZON CITY )S.S.


AFFIDAVIT OF LOSS
1. _________________________, of legal age, Filipino and a resident of
____________________________________________________,after being sworn to in
accordance with law, hereby depose and say, THAT:
2. I am registered owner /operator of the motor vehicle described as follows:
Mae/!ype : ___________ ".#. $o. : __________
Motor $o. : ___________ "%rrent &.#. $o.: __________
"hasis $o. : ___________ File $o. : __________
'late $o. : ___________ "lassification : __________
!rade $ame : ________________
'osition of (ffiant : / / "hairman / / )eneral Manager
/ / 'resident / / &wner
2. &n or abo%t ___ (.M./'.M. of __________, my vehicle was properly pared at
_________________. *hen I ret%rned to retrieve the above+described vehicle on
____________ I noticed that one/both of its plates is/are missing.
,. I lost no time in diligently trying to locate the said plate/s b%t all efforts e-erted
proved f%tile and no to avail, and that the same is considered lost or stolen and beyond
recovery.
/. !he said lost plate/s was/were never lent to another person or entity nor
confiscated by any other law enforcement agency.
0. I bind my self to s%rrender the said plates to the district office that iss%ed the
same in the event that said plates are recovered.
1. If the 2&!" thr% the 3!&/3!F#4, after in5%iry, has fo%nd me responsible for
the %na%thori6ed %se of the herein reported lost plates, hereby signify my conformity to
be meted the administrative fines and penalties d%e and imposed thereon, incl%ding the
gro%nd of the %nit/s covered by the "ertificate of '%blic "onvenience iss%ed thereof,
with waiver and distance on my part for any claim or action by reason of the aforesaid
p%nitive meas%res taen against me.
7. '%rpose of this (ffidavit of 3oss:
/_/ For 3!F#4 'etition for 2ropping and 8%bstit%tion
/_/ For 3!F#4 'etition for 8ale and !ransfer, and/or
/_/ For sec%ring a replacement for lost plates
7. I am e-ec%ting this affidavit for the aforesaid p%rpose/s as well as for attesting
to the tr%th of the statements herein declared, s%b9ect to the r%les on per9%ry.
AFFIANT FURTHER SAYETH NAUGHT.
_______________________
(ffiant
"om. !a- "ert. $o._______
Iss%ed at ______on_______
SUBSCRIBED and SWORN to before me this ____day of ________ 2::/ at
;%e6on "ity, affiant e-hibited to me his/her, comm%nity ta- certificate.
2oc. $o.______ 4oo $o.___
'age $o._____ 8eries of 2:::